Case Manager – Utilization Review Specialist

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Takes on the responsibility and accountability for admission and concurrent reviews.

• Evaluates patient records to assess the validity of admissions, treatments, and duration of stay in healthcare facilities.

• Compares inpatient medical documentation against established criteria.

• Extracts data from records and maintains statistical information.

• Establishes patient review dates based on defined diagnostic criteria.

• Facilitates first, second, and third level appeals.

• Oversees the appeals process to ensure submissions are timely.

• Builds professional relationships with payer appeals and utilization departments.

• Prepares and delivers presentations on appeals to relevant committees.

⛳️ Requirements

• Valid RN license issued by the state.

• Extensive experience in the healthcare industry, including at least five years as a clinical nurse in an acute care environment.

• Preferred experience of five to seven years in case management, discharge planning, and/or utilization review.

• Familiarity with regulatory and payer requirements related to Case Management Activities.

• Capacity to critically assess and make decisions regarding complex cases.

• Ability to uphold the confidentiality of patient data and medical records in accordance with HIPAA regulations.

• Strong oral, technical writing, and typing skills.

🏝️ Benefits

• Health insurance.

• Paid time off.

• Flexible work arrangements.

• Opportunities for professional development.